- Next Steps: Get Started Prescribing Buprenorphine!
- How to Assess and Treat Patients with Comorbid Health Issues
- How to Conduct Buprenorphine Induction
- Phases of Buprenorphine Treatment
- Basic Induction and Dosing Guidelines
- Preparing for Induction
- Standard Induction Protocol
- Dealing with Complications During Induction
- Establishing a Maintenance Dose of Buprenorphine
- Tapering and Discontinuation of Patients from Buprenorphine
- Procedure for Detoxification (Medically Supervised Withdrawal)
- How to Establish and Manage a Buprenorphine Practice
- How to Manage Challenging Patients
- How to Comply with Rules, Regulations, and Recordkeeping
- How to Understand Insurance and Billing Issues
- How to Screen for Substance Abuse
- How to Refer Patients to an Addiction Specialist
- Review: What is Buprenorphine?
Preparing for Induction
After determining that a patient is appropriate for buprenorphine treatment, the clinician should do the following before starting induction:
- Conduct a history & physical
- Verify the patient's list of medications, illicit drugs, and alcohol use
- Conduct a brief psychosocial assessment
- Conduct lab testing: liver function tests, urine toxicology screen, pregnancy test
- Have patient review and sign consent forms and treatment agreement
- Determine when and where to start induction (clinic vs. home induction)
- Provide education to the patient about the induction, stabilization, and maintenance processes
- Advise patients not to use opioids for appropropriate amount of time to prevent precipitated withdrawal
- Recommend that the patient get a friend or family member to drive them home if doing clinic-based induction
Preparing for the First Dose
When presenting for their first dose, patients should be in mild to moderate withdrawal. Patients who are dependent on short-acting opioids should abstain from 12 to 24 hours before beginning induction to achieve this; it will take 36 to 72 hours for those dependent on methadone.
It is important to use an objective measure - like the Clinical Opioid Withdrawal Scale (COWS) - to evaluate the patient's withdrawal symptoms prior to induction since patients may exaggerate their symptoms to avoid discomfort. When patients have a COWS score about 12 or 13 (mild to moderate withdrawal), they are ready for their first dose.
The biggest concern in transferring patients from methadone to buprenorphine is precipitated withdrawal. In order to minimize this risk, patients who are maintained on high doses of methadone should be tapered down to a 30 mg daily dose (ideally) just prior to transfer and maintained on this dose for a week.